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A Validated Strategy to Reduce Error in
Electronic Orders
Session # 129, February 13, 2019
Zane Last, PharmD, MBA
Director - Healthcare Analytics & BI
SBH Health System
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Zane Last, PharmD, MBA
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Objectives – Decrease Near-Miss Orders
• Methods – CPOE Hard Stop
– Process Review
– Assessing Error Rates
• Results
• Intervention
• Outcomes
• Implementation Considerations
• References
Agenda
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• Diagnose number of near-miss wrong patient
orders in a CPOE system with a Hard-Wired EHR
process
• Develop strategies to implement a CPOE Double
ID system alert
• Use strategy to assess wrong patient, right order
near-miss
Learning Objectives
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Decrease the number of near-miss wrong-patient orders in a
computerized physician order entry (CPOE) system
• CPOE systems are commonly used to place orders
1-4
– Prevention of medication errors and medication safety
– Production or exacerbation of new medication errors
5-7
• Wrong Patient CPOE Errors:
• Significant morbidity and mortality
8-10
• Efforts to reduce Wrong Patient CPOE errors in our health system led us
to the development of an alert
• Verification of the patients identity by the ordering physician at the
time of CPOE
Objective
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• SBH is the Oldest Continuing Healthcare Facility in the NY City Area
Located in the Bronx, Celebrating its 153
rd
Anniversary
A Not-for-profit, Nonsectarian teaching hospital
Payer Mix of 90% Medicaid/Medicare
• Acute Care:
422 certified hospital beds
Level 2 trauma center
NY State-designated stroke and AIDS center
Over 88,000 emergency room visits annually
Over 17,000 hospital discharges
SBH Health System - Overview
Ambulatory Care:
Over 400,000 outpatient visits annually
NCQA Patient-Centered Medical Home
designation
One of largest providers of Mental
Health services in the Bronx
19 programs with more than 160,000
visits annually
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• A CPOE, hard stop, alert was built and implemented:
– Ordering clinicians were prompted to reaffirm the patients
identity
• Entering the patient’s initials and year of birth prior to
placing an order became mandatory
Methods
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• Multidisciplinary Stakeholder Team
– Senior Leadership
– ED Leadership
– Front-Line Staff
– Representation from all disciplines involved with the CPOE
Process
• Nursing
• Pharmacy
• Radiology
Process Review for CPOE ordering
• Clinical Laboratory
• Information Technology
• Analytics
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Factors Contributing to CPOE Patient ID Errors
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• We utilized a Retract and Reorder tool developed by Adelman et
al
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– Measures the frequency of near-miss wrong-patient order
errors before and after implementation of the alert
• Flags orders placed for one patient, erased, then added to
another patient’s file by the same clinician
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within a 10 minute time
frame
– Identifies near-miss errors self caught by the provider before
causing harm to the patient
– Closely related to other errors that may reach the patient
Assessing Error Rates
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• The ID re-entry function decreased near-miss wrong-patient
orders in our ED by 35% during the 8-week pilot period. The
system was also successful in helping to decrease the percentage
of all CPOE near-miss events by 49%.
• October – December 2014
– 231 near-miss, wrong-patient orders throughout the health
system
• 37% occurring in the Emergency Department
• Approximately 1 near-miss per day in the ED
Results
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• Mandatory ID re-entry functionality:
– Prescriber required to enter the patient’s initials and year of
birth at the beginning of order entry
– In line with TJC’s National Patient Safety Goal
• Two patient identifiers when providing care, treatment,
and services
Intervention
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1
st
Alert: Initiating a New Order
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2
nd
Alert: Incorrect Entry
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3
rd
Alert: Repeat Error
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• Implementation in our ED: November 3, 2015
– Error Rates: 35% reduction
• Prior to intervention: 6.125 events per week
• After intervention: 4 events per week
– Near miss ID Errors in the ED relative to system wide errors
• Decreased from 37% to 19%
• Similar to results by Adelman et al
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– Resident and Attending staff corroborate that ID functionality
does in fact bring awareness to wrong patient selections
• Time studies indicate:
– CPOE ID re-entry added 6.2 seconds to an order entry
session – Experience brings this down to 4.0 seconds
Outcomes
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• Other IT initiatives going live at the same time
• Locations for implementation
– Pilot location: Emergency Department
– Additional Location(s): ICU
• Errors during go live
– No alerts or missing alerts
– Untrained providers experiencing the alert
– Providers locked out of the system after incorrectly
identifying a patient
Implementation Considerations
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• Work-arounds that can lead to identification errors
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– Providers blindly utilize the patient header to enter patients
initials and year of birth by viewing window behind alert
screen
• Workplace interruptions a significant factor
– Create no interruption zones
11-12
• Multiple sign on sessions
– Clinicians utilizing multiple EHR sign-on sessions
• Leading to confusion when toggling between patients on
multiple screens
Errors Can Still Occur!
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• An alert that requires the prescriber to enter the patient’s initials
and birth year is effective in decreasing wrong-patient orders in
the SBH Health System’s Allscripts CPOE system
Conclusion
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1. Bates, DW, Leape L, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention
of serious medication errors. JAMA 1998;280:1311–16.
2. Bates, DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am
Med Inform Assoc 1999;6:313–21.
3. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems
on medication safety: a systematic review. Arch Intern Med 2003;163:1409–16.
4. Reckmann, MH, Westbrook JI, Koh Y, et al. Does computeized provider order entry reduce prescribing errors for hospital
inpatients? A systematic review. J Am Med Inform Assoc 2009;16:613–23.
5. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors.
JAMA 2005;293:1197–203.
6. Broder C. Study: CPOE can increase risk of medication errors. Health IT News. March 9, 2005.
7. Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors: analysis of reported
errors and vulnerability testing of current systems. BMJ Qual Saf 2015;24:264–71.
8. Adelman, JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a
randomized controlled trial. JAM Med Inform Assoc 2013;20:305–10.
9. Yang A, Grissinger M. Pennsylvania Patient Safety Authority. Wrong-patient medication errors: an analysis of event
reports in Pennsylvania and strategies for prevention. PA Patient Saf Advis 2013 June;10:41–9.
10. Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry
system. Ann Emerg Med 2015;65:679–86.
11. Anthony K, Wiencek C, Bauer C, et al. No interruptions please: impact of a No Interruption Zone on medication safety in
intensive care units. Crit Care Nurse 2010;30:21–9.
12. Institute for Safe Medication Practices. Side tracks on the safety express. interruptions lead to errors and unfinished…wait,
what was i doing? 29 Nov 2012. Accessed at: www.ismp.org/Newsletters/acutecare/showarticle.aspx?id=37
References
